In the majority of cases where fraud charges have been filed against emergency medical services and fire departments, the problems are normally traced back to their billing process. Unfortunately in these cases, ignorance of the regulations is not valid in defending a prosecution. In order to avoid the possibility of a fraud investigation, EMS managers need to have a clear and thorough understanding of current regulations. A number of common errors have been identified, these common errors are:-
- Fee schedules
- Internal Procedures
Fee schedules – In the case of fire departments, this typically relates to the adoption of the fee schedules and structures set out by ambulance services. Billing methods and inappropriate charges are the most common errors.
Coding errors – Insurance companies and Medicare reimburse transportation by ambulance once it has been confirmed the transport was “medically necessary”, based on the condition of the patient when transport was provided. A code system has been introduced to aid the billing process and Medicare requires claims are submitted with at least one diagnosis code (ICD Code) as outlined in the International Classification of Disease manual. Since the development of the ICD codes used as the final diagnoses, the use of them in ambulance transport coding is complex at its best, and at its worst, an opportunity for fraudulent claims by departments, knowingly or unknowingly. Unless billing staff members are sufficiently trained in the interpretation of the information and able to select the correct codes, it becomes possible for an incorrect code to be submitted unwittingly.
Procedural errors – In fire departments, this is the most frequent type of error, typically due to lack of knowledge or understanding of insurance and Medicare regulations with regards to the services of ambulance transport. As far as Medicare are concerned, ignorance is no defense.
Next week ABS Inc. will continue this theme by going a little deeper in to the issues and highlight the importance of their business when it comes to helping you in preventing any potential fraud investigation against your business.